Please complete and sign this Application, along with any required supplemental forms identified through this application process.

Transcription

1 Getting Started Please complete and sign this Application, along with any required supplemental forms identified through this application process. In order to complete this Application, you will need some or all of the following information: Identification information, such as a driver s license, passport, or another type of government-issued identification (a copy is required): o Public depositors need not provide detail on personal information, however, must provide a board resolution or equivalent for their approval to transact on behalf of the entity Company Tax Identification Number/Social Security Number Back-up contact information Current documentation of Corporate Signer Authority. Acceptable documents would be Articles of Incorporation, Resolution of Authority, Certificate of Good Standing, Corporate Resolution or State Filing of Incorporation. erti ication o ene icia ner s The above information helps us comply with various regulations and rules and the USA PATRIOT Act, a Federal law that requires certain companies to obtain, verify, and record information that identifies each applicant. Please note: if we cannot verify the information you provide, we may be required to restrict or deny your account. 1 Select an Account Account Type Public Entity (includes municipalities, school districts, and more) ccredited Investor (includes trusts) Corporate ntit (includes non-profit, LLC, corporations) Other Accounts Do you have other accounts with us? Yes No Bond Proceed Information Are the funds in this account the proceeds from an issuance of a bond or other type financing? Yes No If yes, please complete Arbitrage Rebate Reporting Election form. American Deposit Management, LLC

2 2 Please Tell Us about Your Entity Entity Information Name o ntit or ccredited Investor TIN SS # Alternative Name Permanent Address Suite No. City State ZIP Code County/Country Main Phone Fax Number Alternative Number Web Address Mailing Address (if different from above) Apt/Suite No. City State ZIP Code County/Country Classification Type: LLC DBA Corporation Non-Profit Public Entity r st USA PATRIOT Act Information (Required by Federal law See page 1) All authorized signers must provide the information requested below. Non-resident aliens, also include a completed W-8BEN. PUBLIC ENTITIES DO NOT NEED TO PROVIDE PERSONAL INFORMATION. Authorized Signer #1 First Name Middle Name Last Name Title Date of Birth (mm/dd/yyyy) Social Security or Taxpayer ID No. Address ID No. (Select one): Driver s License Passport State ID Other Government-issued ID Place/Country of Issuance Issue Date (mm/yyyy) Expiration Date (mm/yyyy) Work Phone Authorized Signer #2 First Name Middle Name Last Name Title Date of Birth (mm/dd/yyyy) Social Security or Taxpayer ID No. Address ID No. (Select one): Driver s License Passport State ID Other Government-issued ID Place/Country of Issuance Issue Date (mm/yyyy) Expiration Date (mm/yyyy) Work Phone American Deposit Management, LLC

3 2 Please Tell Us about Yourself CONTINUED Additional Employees (Make a copy of this form for each additional employee.) Contact Information Mr. Mrs. Ms. Dr. Suffix Sr. Jr. First Name Middle Name Last Name Use the same contact information listed for the authorized signers. Permanent Address Corporate Title: City State ZIP Code SSN# Work Phone Cell Phone Drivers License # and Exp Date Mailing Address (if different from above) Suite No. City State ZIP Code Country Additional employee is authorized for the following: Conduct all business on behalf of entity. Information reporting only, including e-statement access. Please note that additional employees may not request a change of authorized signer. American Deposit Management, LLC

4 2 Please Tell Us about Yourself CONTINUED Company Information Industry and Other Affiliations isit nai o ear h to ocate o r code NAICS Code Industry Years in Business and Nature of Business Activity 3 Bank Information Primary Bank Information For purposes of interest payments and withdrawal requests, we need your primary bank account information so we can credit your account accordingly. Please provide the information below: Bank Name Branch Name (if known) How long have you banked here? Address Suite No. City State ZIP Code Country Phone Website Routing Number Account Number for funds deposit Contact Person: Phone Number: Address: This is an: Operating Account (checking) Is debit blocker or debit filter service used on this account? Yes o Money Market Account (savings) Is debit blocker or debit filter service used on this account? Yes No Other (please explain): Please note that you will need to contact your primary bank to authorize American Deposit Management, LLC as an approved Automated Clearing House (ACH) originator for your account. All new accounts require an ACH pre-notification as part of the account opening procedure. American Deposit Management, LLC

5 4 Tell Us How You Will Fund This Account Please tell us how you are funding this account: Check Wire Transfer ACH 5 Tell Us How You Want to Work With Us Interest Management Check one of the following options*: ACH monthly interest to operating account (listed in Section 3) Reinvest in the same account *Your election may be changed at anytime by written request. Additional e-statement Access (optional) Please provide e-statement access to the person listed below: Mr. Mrs. Ms. Dr. Suffix Sr. Jr. First Name Middle Name Last Name Title Mailing Address Address City State ZIP Code Phone Number Relationship to Primary Applicant: American Deposit Management, LLC

6 6 Review and Submit This Application Confirmations and Signatures Please Read Carefully By signing this Application, you affirm that you have received and read this Application, account terms and conditions, and any supplemental documents governing this relationship. You affirm that the information you have provided is accurate and you agree to notify us of any changes in the information provided, including ANY change of signers. ients other than p ic nit depositors represent and arrant that the are an accredited investor as that ter is de ined app ica e sec rities a s and the Sec rities and chan e o ission Authorized Signers on behalf of the Organization: Name (please print) Title Signature Date Name (please print) Title Signature Date By initialing this box, you authorize American Deposit Management LLC ( ADM ) to share this application, and/or the information contained herein, with your financial institution or advisor ( referring agent ), its representatives and employees. You further acknowledge that your referring agent may receive compensation from ADM for funds placed into the program. Additionally, you acknowledge and agree that the fees ADM charges for its services are separate and distinct from the fees your referring agent charges or may charge to Applicant for services and that Applicant will be responsible for payment of ADM's fees. If you have questions on this application, please contact C ient Ser i e at o begin the account opening process, return your o p ete application u ing one o the o o ing etho ax to ai to ient er i e a eri an epo it o ai to American Deposit Management, LLC. Attn C ient Ser i e Spring a e e au ee, WI 530 American Deposit Management, LLC

7 CERTIFICATION OF BENEFICIAL OWNER(S) Persons opening an account on behalf of a Legal Entity must provide the following information: a. Name and Title of Natural Person opening account: b. Name, Type, and Address of Legal Entity for which the account is being opened: c. The following information for each individual*, if any, who directly or indirectly, through any contract, arrangement, understanding, relationship, or otherwise, owns 25% or more of the equity interests of the Legal Entity listed above: Name Date of Birth Address (Residential or Business Street Address) For U.S. Persons: Social Security Number For Non-U.S. Persons: Social Security Number, Passport Number and Country of Issuance, or other similar identification number 1 % of Ownership *If no individual meets this definition, please enter Not Applicable above and explain below (i.e. All <25%; Charity/Non-Profit; etc.): Beneficial Owner Detail: As applicable, explain any layers of Beneficial Ownership, etc. (For example, ABC Co. is 50% owned by 123 Corp. 123 Corp. is 50% owned by John Doe; therefore, John is a 25% Beneficial Owner of ABC Co.) d. The following information for one individual with significant responsibility for managing the Legal Entity listed above: An executive officer or senior manager (e.g. Chief Executive Officer, Chief Financial Officer, Chief Operating Officer, Managing Member, General Partner, President, Vice President, Treasurer); or, Any other individual who regularly performs similar functions. (If appropriate, an individual listed under section (c) above may also be listed in this section (d)). Name/Title Date of Birth Address (Residential or Business Street Address) For U.S. Persons: Social Security Number For Non-U.S. Persons: Social Security Number, Passport Number and Country of Issuance, or other similar identification number 1 I, (name of natural person opening account), hereby certify, to the best of my knowledge, that the information above is complete and correct and have the requisite authority to sign the form and open the account. SIGNATURE: DATE: Legal Entity Identifier (Optional): 1 In lieu of a passport number, Non-U.S. persons may also provide a Social Security Number, an alien identification card number, or number and country of issuance of any other government-issued document evidencing nationality or residence and bearing a photograph or similar safeguard.

8 Bank/Credit Union Exclusion Worksheet New Account Exclusion List Please list any financial institutions in which you currently have funds on deposit. This is limited to FDIC or NCUA insured products such as Certificates of Deposit (CD), Money Market, Checking or Savings Accounts. You do not need to provide account numbers. Client Name: Name of Financial Institution City State Completed By: Date: Signature: **Bank funding worksheet is accurate as of the date submitted. Unless otherwise notified, ADM will use this as the primary listing of all excluded banks. Any new or additional accounts opened by the customer, must be communicated to ADM to ensure proper FDIC coverage on all deposits of the customer. Entered by: American Verified Deposit Management, LLC by: R0112. All Rights Reserved